ANNEX 1 – ANTHROPOMETRIC MEASUREMENT TECHNIQUES

Checking for bilateral oedema

Bilateral oedema is the sign of Kwashiorkor. Kwashiorkor is always a severe form of malnutrition.

Children with bilateral oedema are directly identified to be acutely malnourished. These children are at high risk of mortality

and need to be treated in a therapeutic feeding program urgently.

In order to determine the presence of oedema,

Normal thumb pressure is applied to the both feet for at least three seconds.

If a shallow print persists on the both feet, then the child has oedema. Only children with bilateral oedema are recorded as having nutritional oedema1.

You must formally test for œdema with finger pressure, You cannot tell by just looking

1 There are other causes of bilateral oedema (e.g. nephritic syndrome) but they all require admission as an inpatient.

Taking MUAC

MUAC is used as an alternative measure of “thinness” to weight-for-height. It is particularly used in children from

one to five years: however, its use has been extended to include children more than 6 months (under 67cm in height).

Ask the mother to remove clothing that may cover the child’s left arm.

Calculate the midpoint of the child’s left upper arm. This can be done by taking a piece of string (or the tape itself), place one end on the tip of the child’s shoulder (arrow 1) and the other on the elbow (arrow 2), now bend the string up in a loop to double it so the point at the elbow is placed together with the point on the shoulder with a loop hanging down – the end of the straightened loop indicates the mid-point.

As an alternative, place the tape at zero, which is indicated by two arrows, on the tip of the shoulder (arrow 4) and pull the tape straight down past the tip of the elbow (arrow 5). Read the number at the tip of the elbow

to the nearest centimetre.

Divide this number by two to estimate the midpoint. Mark the midpoint with a pen on the arm (arrow 6).

Straighten the child’s arm and wrap the tape around the arm at the midpoint. Make sure the numbers are right side up.

Make sure the tape is flat around the skin (arrow 7).

Inspect the tension of the tape on the child’s arm. Make sure the tape has the proper tension (arrow 7) and is not too tight so that the skin is compressed or too loose so that the tape does not contact the skin all the way round the arm (arrows 8 and 9).

Repeat any step as necessary.

When the tape is in the correct position on the arm with correct tension, read and call out the measurement to the nearest 0.1cm (arrow 10).

Immediately record the measurement.

Taking the weight

Children may be weighed by using a 25 kg hanging sprint scale graduated to 0.100 kg or an electronic balance (e.g. UNISCALE).

Do not forget to re-adjust the scale to zero before each weighing.

A plastic washing-basin should be attached by 4 ropes that go underneath the basin.

The basin needs to be close to the ground in case the child falls out, and to make the child feel secure during weighing.

If the basin is dirtied then it should be cleaned with disinfectant. This is much more comfortable and familiar for the child, can be used for ill children and is easily cleaned. Weighing pants that are used during surveys should not be used; they are uncomfortable, difficult to use, inappropriate for sick children and quickly get soiled to pass an infection to the next patient.

When the child is steady, read the measurement to the nearest 100 grams, with the frame of the scale at eye level.

Each day, the scales must be checked by using a known weight.

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Taking the length/height

For children less than 87 cm, the measuring board is placed on the ground. The child is placed, lying along the middle of the board. The assistant holds the sides of the child’s head and positions the head until it firmly touches the fixed headboard with the hair compressed. The measurer places her hands on the child’s legs, gently stretches the child and then keeps one hand on the thighs to prevent flexion. While positioning the child’s legs, the sliding foot-plate is pushed firmly against the bottom of the child’s feet. To read the measure, the foot-plate must be perpendicular to the axis of the board and vertical. The height is read to the nearest 0.1 centimetre.

©Shorr Productions

The longer lines indicate centimetre marking; the shorter lines indicate millimetre.

©WHO Growth standard training

For children more than 87 cm, the measuring board is fixed upright where the ground is level. The child stands, upright in the middle, against the measuring board. The child’s head, shoulders, buttocks, knees, heels are held against the board

by the assistant, while the measurer positions the head and the cursor. The height is read to the nearest 0.1 centimetre.

Detail of the

measurement

©WHO Growth standard training

©Shorr Productions

Weight/Height Z-score using unisex table How to use the weight/height z-score tables?

Example: a child is 63 cm length and weighs 6.5 kg.

Take the table, look in the 1st column and look for the figure 63cm (=height).

Take a ruler or a piece of card place it under the figure 63 and the other figures on the same line. On this line find the figure corresponding to the weight of the child, in this case 6.8.

Look to see what column this figure is in. In this case it is in the MEDIAN WEIGHT column. In this example the child’s weight is normal in relation to his LENGHT. He therefore has an appropriate weight for his length.

Example: a child is 78 cm tall and weighs 8.3 kg

This child is between the column -2 & -3 Z-score or between MAM and SAM. He is too thin in relation to his length or

less than -2 and more than -3; he is <-2 (less) and >-3 (more): he is MODERATELY MALNOURISHED but NOT Severely Malnourished.

NOTE: It may be that the weight or the height is not a whole number.

Example: length: 80.4 cm and weight 7.9 kg. These 2 figures are not in the table.

For the height/length: The height/length measurement has to be rounded to the nearest 0.5cm, as it is in the following example.

LENGHT in cm

80.0

80.1

80.2

80.3 80.4

80.5 80.6

80.7 80.8

80.9 81.0 81.1 81.2 For the weight: Looking at the table, for a length of 80.5 cm the weight is 7.9 kg. This is between 7.7 and 8.3 kg. Conclusion, to express the fact that the child is between these 2 weights, write down that this child’s Z-score is between -4 and -3 Z-score or <-3 AND >-4 Z-score. The child has SAM.

80.0cm is used for:

80.1 and 80.2cm

80.5cm is used for:

80.3 and 80.4cm 80.5cm is used for:

80.6 and 80.7cm

81.0cm is used for:

80.8, 80.9 cm as well as 81.1

and 81.2 cm

ANNEX 2 – WEIGHT-FOR-HEIGHT TABLE (WHO2006)

Use for both boys and girls

Length Weight Kg – Z-score

Length

Weight Kg – Z-score

very severe severe SAM moderate MAM discharge IMAM median

very severe severe SAM moderate MAM discharge IMAM Median

cm -4.0 -3 -2 -1.5 -1 0 cm

-4.0 -3 -2 -1.5 -1 0

Use Length for less than 87 cm

45 1.73 1.88 2.04 2.13 2.23 2.44

66 5.5 5.9 6.4 6.7 6.9 7.5

45.5 1.79 1.94 2.11 2.21 2.31 2.52

66.5 5.6 6 6.5 6.8 7 7.6

46 1.85 2.01 2.18 2.28 2.38 2.61

67 5.7 6.1 6.6 6.9 7.1 7.7

46.5 1.91 2.07 2.26 2.36 2.46 2.69

67.5 5.8 6.2 6.7 7 7.2 7.9

47 1.97 2.14 2.33 2.43 2.54 2.78

68 5.8 6.3 6.8 7.1 7.3 8

47.5 2.04 2.21 2.40 2.51 2.62 2.86

68.5 5.9 6.4 6.9 7.2 7.5 8.1

48 2.10 2.28 2.48 2.58 2.70 2.95

69 6.0 6.5 7 7.3 7.6 8.2

48.5 2.17 2.35 2.55 2.66 2.78 3.04

69.5 6.1 6.6 7.1 7.4 7.7 8.3

49 2.23 2.42 2.63 2.75 2.87 3.13

70 6.2 6.6 7.2 7.5 7.8 8.4

49.5 2.31 2.50 2.71 2.83 2.96 3.23

70.5 6.3 6.7 7.3 7.6 7.9 8.5

50 2.38 2.58 2.80 2.92 3.05 3.33

71 6.3 6.8 7.4 7.7 8 8.6

50.5 2.46 2.66 2.89 3.01 3.14 3.43

71.5 6.4 6.9 7.5 7.8 8.1 8.8

51 2.54 2.75 2.98 3.11 3.24 3.54

72 6.5 7 7.6 7.9 8.2 8.9

51.5 2.62 2.83 3.08 3.21 3.34 3.65

72.5 6.6 7.1 7.6 8 8.3 9

52 2.70 2.93 3.17 3.31 3.45 3.76

73 6.6 7.2 7.7 8 8.4 9.1

52.5 2.79 3.02 3.28 3.41 3.56 3.88

73.5 6.7 7.2 7.8 8.1 8.5 9.2

53 2.88 3.12 3.38 3.53 3.68 4.01

74 6.8 7.3 7.9 8.2 8.6 9.3

53.5 2.98 3.22 3.49 3.64 3.80 4.14

74.5 6.9 7.4 8 8.3 8.7 9.4

54 3.08 3.33 3.61 3.76 3.92 4.27

75 6.9 7.5 8.1 8.4 8.8 9.5

54.5 3.18 3.55 3.85 4.01 4.18 4.55

75.5 7.0 7.6 8.2 8.5 8.8 9.6

55 3.29 3.67 3.97 4.14 4.31 4.69

76 7.1 7.6 8.3 8.6 8.9 9.7

55.5 3.39 3.78 4.10 4.26 4.44 4.83

76.5 7.2 7.7 8.3 8.7 9 9.8

56 3.50 3.90 4.22 4.40 4.58 4.98

77 7.2 7.8 8.4 8.8 9.1 9.9

56.5 3.61 4.02 4.35 4.53 4.71 5.13

77.5 7.3 7.9 8.5 8.8 9.2 10

57 3.7 4 4.3 4.5 4.7 5.1

78 7.4 7.9 8.6 8.9 9.3 10.1

57.5 3.8 4.1 4.5 4.7 4.9 5.3

78.5 7.4 8 8.7 9 9.4 10.2

58 3.9 4.3 4.6 4.8 5 5.4

79 7.5 8.1 8.7 9.1 9.5 10.3

58.5 4.0 4.4 4.7 4.9 5.1 5.6

79.5 7.6 8.2 8.8 9.2 9.5 10.4

59 4.2 4.5 4.8 5 5.3 5.7

80 7.6 8.2 8.9 9.2 9.6 10.4

59.5 4.3 4.6 5 5.2 5.4 5.9

80.5 7.7 8.3 9 9.3 9.7 10.5

60 4.4 4.7 5.1 5.3 5.5 6

81 7.8 8.4 9.1 9.4 9.8 10.6

60.5 4.5 4.8 5.2 5.4 5.6 6.1

81.5 7.8 8.5 9.1 9.5 9.9 10.7

61 4.6 4.9 5.3 5.5 5.8 6.3

82 7.9 8.5 9.2 9.6 10 10.8

61.5 4.7 5 5.4 5.7 5.9 6.4

82.5 8.0 8.6 9.3 9.7 10.1 10.9

62 4.8 5.1 5.6 5.8 6 6.5

83 8.1 8.7 9.4 9.8 10.2 11

62.5 4.9 5.2 5.7 5.9 6.1 6.7

83.5 8.2 8.8 9.5 9.9 10.3 11.2

63 5.0 5.3 5.8 6 6.2 6.8

84 8.3 8.9 9.6 10 10.4 11.3

63.5 5.1 5.4 5.9 6.1 6.4 6.9

84.5 8.3 9 9.7 10.1 10.5 11.4

64 5.1 5.5 6 6.2 6.5 7

85 8.4 9.1 9.8 10.2 10.6 11.5

64.5 5.2 5.6 6.1 6.3 6.6 7.1

85.5 8.5 9.2 9.9 10.3 10.7 11.6

65 5.3 5.7 6.2 6.4 6.7 7.3

86 8.6 9.3 10 10.4 10.8 11.7

65.5 5.4 5.8 6.3 6.5 6.8 7.4

86.5 8.7 9.4 10.1 10.5 11 11.9

Use for both boys and girls

Height Weight Kg – Z-score

Height Weight Kg – Z-score

very severe severe SAM moderate MAM

discharge IMAM

median

very severe severe SAM

moderate MAM discharge

IMAM Median

Cm -4.0 -3 -2 -1.5 -1 0

cm -4.0 -3 -2 -1.5 -1 0

Use Height for more than or equal to 87 cm

87 9.0 9.6 10.4 10.8 11.2 12.2

104 12.0 13 14 14.6 15.2 16.5

87.5 9.0 9.7 10.5 10.9 11.3 12.3

104.5 12.1 13.1 14.2 14.7 15.4 16.7

88 9.1 9.8 10.6 11 11.5 12.4

105 12.2 13.2 14.3 14.9 15.5 16.8

88.5 9.2 9.9 10.7 11.1 11.6 12.5

105.5 12.3 13.3 14.4 15 15.6 17

89 9.3 10 10.8 11.2 11.7 12.6

106 12.4 13.4 14.5 15.1 15.8 17.2

89.5 9.4 10.1 10.9 11.3 11.8 12.8

106.5 12.5 13.5 14.7 15.3 15.9 17.3

90 9.5 10.2 11 11.5 11.9 12.9

107 12.6 13.7 14.8 15.4 16.1 17.5

90.5 9.6 10.3 11.1 11.6 12 13

107.5 12.7 13.8 14.9 15.6 16.2 17.7

91 9.7 10.4 11.2 11.7 12.1 13.1

108 12.8 13.9 15.1 15.7 16.4 17.8

91.5 9.8 10.5 11.3 11.8 12.2 13.2

108.5 13.0 14 15.2 15.8 16.5 18

92 9.9 10.6 11.4 11.9 12.3 13.4

109 13.1 14.1 15.3 16 16.7 18.2

92.5 9.9 10.7 11.5 12 12.4 13.5

109.5 13.2 14.3 15.5 16.1 16.8 18.3

93 10.0 10.8 11.6 12.1 12.6 13.6

110 13.3 14.4 15.6 16.3 17 18.5

93.5 10.1 10.9 11.7 12.2 12.7 13.7

110.5 13.4 14.5 15.8 16.4 17.1 18.7

94 10.2 11 11.8 12.3 12.8 13.8

111 13.5 14.6 15.9 16.6 17.3 18.9

94.5 10.3 11.1 11.9 12.4 12.9 13.9

111.5 13.6 14.8 16 16.7 17.5 19.1

95 10.4 11.1 12 12.5 13 14.1

112 13.7 14.9 16.2 16.9 17.6 19.2

95.5 10.4 11.2 12.1 12.6 13.1 14.2

112.5 13.9 15 16.3 17 17.8 19.4

96 10.5 11.3 12.2 12.7 13.2 14.3

113 14.0 15.2 16.5 17.2 18 19.6

96.5 10.6 11.4 12.3 12.8 13.3 14.4

113.5 14.1 15.3 16.6 17.4 18.1 19.8

97 10.7 11.5 12.4 12.9 13.4 14.6

114 14.2 15.4 16.8 17.5 18.3 20

97.5 10.8 11.6 12.5 13 13.6 14.7

114.5 14.3 15.6 16.9 17.7 18.5 20.2

98 10.9 11.7 12.6 13.1 13.7 14.8

115 14.5 15.7 17.1 17.8 18.6 20.4

98.5 11.0 11.8 12.8 13.3 13.8 14.9

115.5 14.6 15.8 17.2 18 18.8 20.6

99 11.1 11.9 12.9 13.4 13.9 15.1

116 14.7 16 17.4 18.2 19 20.8

99.5 11.2 12 13 13.5 14 15.2

116.5 14.8 16.1 17.5 18.3 19.2 21

100 11.2 12.1 13.1 13.6 14.2 15.4

117 15.0 16.2 17.7 18.5 19.3 21.2

100.5 11.3 12.2 13.2 13.7 14.3 15.5

117.5 15.1 16.4 17.9 18.7 19.5 21.4

101 11.4 12.3 13.3 13.9 14.4 15.6

118 15.2 16.5 18 18.8 19.7 21.6

101.5 11.5 12.4 13.4 14 14.5 15.8

118.5 15.3 16.7 18.2 19 19.9 21.8

102 11.6 12.5 13.6 14.1 14.7 15.9

119 15.4 16.8 18.3 19.1 20 22

102.5 11.7 12.6 13.7 14.2 14.8 16.1

119.5 15.6 16.9 18.5 19.3 20.2 22.2

103 11.8 12.8 13.8 14.4 14.9 16.2

120 15.7 17.1 18.6 19.5 20.4 22.4

103.5 11.9 12.9 13.9 14.5 15.1 16.4

These tables are derived from the WHO2006 standards for Boys. Because using separate tables for boys and girls may lead to many more boys being admitted to therapeutic programs than girls, the use of the boys table for both sexes is recommended to avoid discrimination against female children. It is recommended that the discharge criteria should be -1.5Z where there are adequate follow up arrangements and/or a supplementary feeding program to which the children can be referred. © Michael Golden

ANNEX 3 – EXAMPLE S OF RECIPES FOR F75, F100 AND RESOMAL USING CMV

Note that all these recipes give products that have a higher osmolarity than the commercial packaged products and are more

likely to provoke refeeding diarrhoea. They can be used when there is no possibility of pre-packaged products being available

and there are adequate kitchen facilities and expertise to make the diets – ALL the ingredients must be present.

*F75

Type of milk Milk (g) Eggs (g) Sugar (g) Oil (g) Cereal powder (g)*

CMV**

(red scoop=6g)

Water (ml)

Dry Skim Milk 25 0 70 27 35 ½ Up to 1000

Dry Whole Milk 35 0 70 20 35 ½ Up to 1000

Fresh cow milk 280 0 65 20 35 ½ Up to 1000

Fresh goat milk 280 0 65 20 40 ½ Up to 1000

Fresh buffalo milk 230 0 65 15 40 ½ Up to 1000

Evaporated milk 110 0 65 20 40 ½ Up to 1000

Whole Eggs 0 80 70 20 40 ½ Up to 1000

Egg yolks 0 50 70 15 40 ½ Up to 1000

* Cereal powder should be roasted (“puffed”) and then ground finely and the other ingredients should be added. Alternatively “puffed” rice or roasted flour can be added to the mixure. ** CMV = Special Mineral and Vitamin mix adapted to severe acute malnutrition treatment

*F100 Type of milk Milk (g) Eggs (g) Sugar (g) Oil

(g) CMV**

(red scoop=6g) Water (ml)

Dry Skim Milk 80 0 50 60 ½ Up to 1000

Dry Whole Milk 110 0 50 30 ½ Up to 1000

Fresh cow milk 900 0 50 25 ½ Up to 1000

Fresh goat milk 900 0 50 30 ½ Up to 1000

Fresh Buffalo milk 750 0 60 10 ½ Up to 1000

EVAPORATED milk 350 0 50 30 ½ Up to 1000

Whole eggs 0 220 90 35 ½ Up to 1000

Egg yolks 0 170 90 10 ½ Up to 1000

*ReSoMal Ingredient Amount

Standard WHO-ORS one l-litre packet

CMV**(Mineral &Vitamin mix) 1 red scoop (6 gr.)

Sucrose (sugar) 50 g

Water 2000 ml

SIGNS OF SHOCK None Lethargic/unconsious Cold hand Slow capillary refill(>3 seconds) Weak/fast pulse

If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. Give IV glucose as described under Blood Glucose (left). Then give IV fluids:

Amount IV fluids per hour: 15 ml x kg (child’s wt) = ml

Start: Monitor every 10 minutes *2nd hr: Monitor every 10 minutes

Time *

Resp. rate *

Pulse rate *

*If respiratory & pulse rates are slower after 1 hour, repeat same amount IV fluids for 2nd hour; then alternate ReSoMal and F-75 for up to 10 hours as in right part of chart below. If no improvement on IV fluids, transfuse whole fresh blood. (See left, Haemoglobin.)

DIARRHOEA Watery diarrhoea? Yes No If diarrhoea, Skin pinch goes back slowly Blood in stool? Yes No circle signs Restless/irritable Lethargic Thirsty Vomiting? Yes No present: Sunken eyes Dry mouth/tongue No tears

If diarrhoea and/or vomiting, give ReSoMal. Every 30 minutes for first 2 hours, monitor and give:*

5 ml x kg (child’s wt) = ml ReSoMal

Commence F-75 after 2 hours, then for up to 10 hours, give ReSoMal and F-75 in alternate hours. Monitor every hour. Amount of ReSoMal to offer:*

5 to 10 ml x kg (child’s wt) = to ml ReSoMal Time Start: Resp. rate Pulse rate Passed urine? Y N Number stools Number vomits Hydration signs

Amount taken (ml) F-75 F-75 F-75 F-75 F-75

*Stop ReSoMal if: Increase in pulse & resp. rates Jugular veins engorged Increasing oedema, e.g., puffy eyelids

CRITICAL CARE PATHWAY (CCP) — SEVERE MALNUTRITION WARD NAME M F DATE OF BIRTH OR AGE DATE OF ADMISSION TIME HOSP. ID NUMBER_

INITIAL MANAGEMENT

Comments on pre-referral and/or emergency treatment already given:

SIGNS OF SEVERE MALNUTRITION Severe wasting? Yes No Oedema? 0 + ++ +++ Dermatosis? 0 + ++ +++ (raw skin, fissures) Weight(kg): Height/length (cm): SD score: or % of median:

TEMPERATURE °C rectal axillary

If rectal <35.5°C (95.9°F), or axillary<35°C (95°F), actively warm child. Check temperature every 30 minutes.

BLOOD GLUCOSE (mmol/l): If <3mmol/l and alert, give 50 ml bolus of 10% glucose or sucrose (oral or NG). If <3 mmol/l and lethargic, unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x kg (child’s wt) = ml Then give 50 ml bolus NG.

Time glucose given: Oral NG IV HAEMOGLOBIN (Hb) (g/l): or Packed cell vol (PCV): Blood type: If Hb <40 g/l or PCV<12%, transfuse 10 ml/kg whole fresh blood (or 5-7 ml/kg packed cells) slowly over 3 hours. Amount: Time started: Ended:

EYE SIGNS None Left Right MEASLES Yes No itot’s spots Pus/Inflammation Corneal clouding Corneal ulceration

If ulceration, give vitamin A & atropine immediately. Record on Daily Care page. Oral doses vitamin A: <6 months 50 000 IU

6 - 12 months 100 000 IU >12 months 200 000 IU

FEEDING Begin feeding with F-75 as soon as possible. (If child is rehydrated, reweigh before determining amount to feed. New weight: kg)

Amount for 2-hourly feedings: ml F-75* Time first fed:

* If hypoglycaemic, feed ¼ of this amount every half hour for first 2 hours; continue until blood glucose reaches 3 mmol/l.

Record all feeds on 24-hour Food Intake Chart.

ANTIBIOTICS (All receive) Drug / Route Dose / Frequency / Duration Time of 1st dose

ANNEX 5 – WEIGHT LOSS AND WEIGHT GAIN BY 5% CHART

Ist week loss 2nd week Ist week loss 2nd week initial gain final initial gain final

4,0 0,2 3,8 8,0 0,4 7,6 4,0 0,2 4,2 8,0 0,4 8,4

4,1 0,2 3,9 8,1 0,4 7,7 4,1 0,2 4,3 8,1 0,4 8,5

4,2 0,2 4,0 8,2 0,4 7,8 4,2 0,2 4,4 8,2 0,4 8,6

4,3 0,2 4,1 8,3 0,4 7,9 4,3 0,2 4,5 8,3 0,4 8,7

4,4 0,2 4,2 8,4 0,4 8,0 4,4 0,2 4,6 8,4 0,4 8,8

4,5 0,2 4,3 8,5 0,4 8,1 4,5 0,2 4,7 8,5 0,4 8,9

4,6 0,2 4,4 8,6 0,4 8,2 4,6 0,2 4,8 8,6 0,4 9,0

4,7 0,2 4,5 8,7 0,4 8,3 4,7 0,2 4,9 8,7 0,4 9,1

4,8 0,2 4,6 8,8 0,4 8,4 4,8 0,2 5,0 8,8 0,4 9,2

4,9 0,2 4,7 8,9 0,4 8,5 4,9 0,2 5,1 8,9 0,4 9,3

5,0 0,3 4,8 9,0 0,5 8,6 5,0 0,3 5,3 9,0 0,5 9,5

5,1 0,3 4,8 9,1 0,5 8,6 5,1 0,3 5,4 9,1 0,5 9,6

5,2 0,3 4,9 9,2 0,5 8,7 5,2 0,3 5,5 9,2 0,5 9,7

5,3 0,3 5,0 9,3 0,5 8,8 5,3 0,3 5,6 9,3 0,5 9,8

5,4 0,3 5,1 9,4 0,5 8,9 5,4 0,3 5,7 9,4 0,5 9,9

5,5 0,3 5,2 9,5 0,5 9,0 5,5 0,3 5,8 9,5 0,5 10,0

5,6 0,3 5,3 9,6 0,5 9,1 5,6 0,3 5,9 9,6 0,5 10,1

5,7 0,3 5,4 9,7 0,5 9,2 5,7 0,3 6,0 9,7 0,5 10,2

5,8 0,3 5,5 9,8 0,5 9,3 5,8 0,3 6,1 9,8 0,5 10,3

5,9 0,3 5,6 9,9 0,5 9,4 5,9 0,3 6,2 9,9 0,5 10,4

6,0 0,3 5,7 10,0 0,5 9,5 6,0 0,3 6,3 10,0 0,5 10,5

6,1 0,3 5,8 10,1 0,5 9,6 6,1 0,3 6,4 10,1 0,5 10,6

6,2 0,3 5,9 10,2 0,5 9,7 6,2 0,3 6,5 10,2 0,5 10,7

6,3 0,3 6,0 10,3 0,5 9,8 6,3 0,3 6,6 10,3 0,5 10,8

6,4 0,3 6,1 10,4 0,5 9,9 6,4 0,3 6,7 10,4 0,5 10,9

6,5 0,3 6,2 10,5 0,5 10,0 6,5 0,3 6,8 10,5 0,5 11,0

6,6 0,3 6,3 10,6 0,5 10,1 6,6 0,3 6,9 10,6 0,5 11,1

6,7 0,3 6,4 10,7 0,5 10,2 6,7 0,3 7,0 10,7 0,5 11,2

6,8 0,3 6,5 10,8 0,5 10,3 6,8 0,3 7,1 10,8 0,5 11,3

6,9 0,3 6,6 10,9 0,5 10,4 6,9 0,3 7,2 10,9 0,5 11,4

7,0 0,3 6,6 11,0 0,5 10,5 7,0 0,3 7,3 11,0 0,5 11,6

7,1 0,4 6,7 11,1 0,6 10,5 7,1 0,4 7,5 11,1 0,6 11,7

7,2 0,4 6,8 11,2 0,6 10,6 7,2 0,4 7,6 11,2 0,6 11,8

7,3 0,4 6,9 11,3 0,6 10,7 7,3 0,4 7,7 11,3 0,6 11,9

7,4 0,4 7,0 11,4 0,6 10,8 7,4 0,4 7,8 11,4 0,6 12,0

7,5 0,4 7,1 11,5 0,6 10,9 7,5 0,4 7,9 11,5 0,6 12,1

7,6 0,4 7,2 11,6 0,6 11,0 7,6 0,4 8,0 11,6 0,6 12,2

7,7 0,4 7,3 11,7 0,6 11,1 7,7 0,4 8,1 11,7 0,6 12,3

7,8 0,4 7,4 11,8 0,6 11,2 7,8 0,4 8,2 11,8 0,6 12,4

7,9 0,4 7,5 11,9 0,6 11,3 7,9 0,4 8,3 11,9 0,6 12,5

8,0 0,4 7,6 12,0 0,6 11,4 8,0 0,4 8,4 12,0 0,6 12,6

5% weight gain (for treatment of dehydration)5% weight loss (for failure-to-respond in OTP)

ANNEX 6 – MEDICINE DOSES IN THE SEVERELY MALNOURISHED ANTIBACTERIALS

Amoxicillin (first line antibiotic, routine treatment in IPF)

Administer oral Oral Oral oral

Dose 50 – 100 mg/kg/d

Presentation suspension

125mg/5ml Suspension 250mg/5ml

capsule 250mg

capsule 500mg

3 – 5 Kg 125 mg * 2 5ml x 2 2.5ml x 2 ½ x 2

5 – 10 kg 250 mg * 2 10ml x 2 5ml x 2 1 x 2 ½ x2

10 – 20 kg 500 mg * 2 10ml x 2 2 x 2 1 x2

20 – 35 kg 750 mg * 2 3 x 2 1½ x2

> 35 kg 1000 mg * 2 4 x 2 2 x2

1) Dose not normally critical can be doubled. 2) Amoxicillin is supplied as sodium salt – care in case of sodium sensitivity 3) Resistance to amoxicillin is common. 4) May be adverse reactions with some viral infections (Epstein-Bar virus, CMV and possibly HIV)

Ampicillin (need for IV penicillin)

Administer IV, IM

Dose 100-200 mg/kg/d

Presentation 500mg /1g vials

times/day 4

3 – 5 kg 250mg X 4

5 – 10 kg 500mg x 4

10 – 20 kg 1g X 4

20 – 35 kg 2g x 4

> 35 kg 3g x 4

1) IV preferred over IM: injection painful 2) Give by perfusion over at least 30mins, reduce dose with renal impairment 3) DO NOT give alongside Gentamicin (separate IV by at least one hour) or give gentamicin IM as it inactivates the

gentamicin 4) Presented as the Sodium salt – use as low a dose a possible in case of sodium sensitivity (especially in Kwashiorkor

and heart failure)

5) In severe infections use second/third line antibiotics in view of widespread resistance and high sodium administration with large doses

Gentamicin

(first/second line, with signs of infection)

Administer 5mg/kg/d once daily IM/IV IM/IV

Presentation 10 mg/ml 40 mg/ml

2ml vial 2ml vial

<=3 kg 10mg 1 ml x1 0.25 ml x1

3.1-5.0 kg 20mg 2 ml x1 0.5 ml x1

5.1 – 10 kg 40mg 4 ml x1 1 ml x1

10.1 –15 kg 60mg 6 ml x1 1.5 ml x1

15.1 - 20 kg 80mg 8 ml x1 2 ml x1

20-35 kg 140mg 14 ml x1 3.5 ml x1

>35 kg 200mg 20 ml x1 5 ml x1

1) IM or IV. IM preferred if Penicillins/cefotaxime given IV 2) May result in antibioma with poor absorption in severely wasted children 3) Approx 5mg/kg/d once daily but young infants 3.5mg/kg 4) Danger of nephrotoxicity and ototoxicity 5) Do not give IV at the same time as amoxicillin, ampicillin, cloxacillin, cefotaxime (separate by at least one hour as

they inactivate gentamicin) 6) in very severely oedematous children give by estimated oedema free weight

Precaution – if magnesium sulphate is given by IM injection together with gentamicin may cause neuromuscular blockage - monitor respiratory function

Cefotaxime (first/second line, with signs of infection)

Administer IM/ IV

Dose 50-100 mg/kg/d

Presentation 250 mg/ vial

2 times/ day

3 – 5 Kg 100 mg x 2

5 – 10 kg 200 mg x 2

10 – 20 kg 400 mg x2

20 – 35 kg 800 mg x 2

> 35 kg 1g x 2

1) Preferred to ceftriaxone particularly for gram-negative septicaemia 2) Do not give in same infusion as gentamicin -separate by at least one hour; cefotaxime can inactivate the gentamicin 3) IM injection is very painful use lidocaine containing diluent 4) IV injection do not dilute with lidocaine 5) May deplete vitamin K in liver, if prolonged usage considered give vitamin K 6) In severe infections frequency can be increased to 4 times daily

Ciprofloxacin (second line, septicaemia, septic shock)

Administer Dose oral IV

Presentation 30mg/kg/d 250mg 2mg/ml

3 times/ day tablet Vial

3 – 5 Kg 50 mg x 3 1/4 tab x3 25 ml x3

5 – 10 kg 100 mg x 3 1/2 tab x3 50 ml x3

10 – 20 kg 200 mg x 3 1 tab x3 100 ml x3

20 – 35 kg 400 mg x 3 2 tab x3 200 ml x3

> 35 kg 800 mg x 3 3 tab x3 400 ml x3

1) Very well absorbed orally - give oral or by NGT on empty stomach if possible - IV reserved for vomiting and very severe infection

2) ORAL give either before or after food 3) Absorption reduced by dairy products (e.g. F75, F100), antacids, calcium, iron and zinc salts - do not give with Zinc

tablets 4) Avoid giving with artemether+lumefantrine (Coartem) 5) DO not give IM 6) IV Infusion concentration not to exceed 2mg/ml 7) Infuse slowly over at least 60mins 8) COMBINE with cefotaxime to prevent emergence of resistance

Cloxacillin (staphylococcal infection)

Administer Dose Oral Oral Oral IM/IV

Presentation 100-200 mg/kg/d 125mg/ml 500mg 1g 500mg/vial

3 times/ day suspension Capsule Capsule vial

3 – 5 Kg 62.5-250mg x3 2ml x 3 1/2 x 3 -- 250mg x 3

5 – 10 kg 100-300mg x3 3ml x 3 1 x 3 1/2 x 3 500mg x 3

10 – 20 kg 250-750mg x3 8ml x 3 2 x 3 1 x 3 1g x 3

20 – 35 kg 1g - 1.5g x3 -- 3 x 3 2 x 3 2g x 3

> 35 kg 2-6g x3 -- 3 x 3 2 x 3 2g x 3

1) For suspected or diagnosed systemic staphylococcal infection (especially staph. Pneumonia) 2) Parenteral therapy preferred for severe infection 3) Supplied as the sodium salt 4) Do not give IV at the same time as gentamicin – separate by at least 1 hour and flush cannula

Metronidazole (small bowel overgrowth, amoebiasis, giardia)

Administer Dose Oral Oral IV

Presentation 10-12 mg/kg/d 40 mg/ml 200 mg 500 mg

1-2 time/ day suspension tablet 100 ml vial

3 – 5 Kg 30-60 mg x1 1 ml x 1 5 ml x 1

5 – 10 kg 60-100 mg x1 2 ml x 1 1/4 x 1 10 ml x 1

10 – 20 kg 120-200 mg x1 4 ml x 1 1/2 x 1 10 ml x 2

20 – 35 kg 250-350 mg x1 10 ml x 1 1 x 1 30 ml x 2

> 35 kg 400-500 mg x1 10 ml x 1 1 x 2 50 ml x 2

1) Very high bioavailability: oral route strongly recommended. Well absorbed rectally 2) Can give a double dose as the first loading dose 3) Use suspension if possible 4) Do not give for more than 7 days 5) WHO recommends reduction of standard dose (30mg/kg/d) to 1/3 with hepatic impairment – in SAM maximum dose

is 10-12mg/kg/d by pharmacodynamics studies 6) Take suspension before food and tablets with or after food

ANTIFUNGALS

Nystatin (gastro-intestinal candidiasis)

Administer Oral

Dose 400,000 IU / d

4 times/ day

3 – 60 Kg 100,000 x 4

1) Not for systemic candidiasis. For Oral, oesophageal, gastric and rectal candidiasis only 2) Dose can be safely increased to 500,000 IU 4 times daily to treat severe gastrointestinal candidiasis 3) Give after meals

Fluconazole (systemic candidiasis and fungal infection)

Administer Dose Oral IV

presentation 3-6mg/kg/d 50mg 2mg/ml

1 time/ day capsule Vial

3 – 5 Kg 15mg/d 1/3 x 1 5ml x 1

5 – 10 kg 30mg/d 1/2 x 1 10ml x 1

10 – 20 kg 60mg/d 1 x 1 20ml x 1

20 – 35 kg 120mg/d 2 x 1 40ml x 1

> 35 kg 200mg/d 4 x 1 50ml x 1

1) Bioavailability of oral preparation is excellent 2) Avoid giving with artemether +lumefantrine (coartem) 3) Oral preparation contains sodium benzoate 4) IV preparation give by SLOW infusion over at least one hour 5) A double dose can be given on the first day of treatment 6) Young infants – give same dose but on alternate days

Miconazole (cutaneous ringworm, candidiasis and other fungal infections)

Presentation Cream or ointment

2%

2 times/ day

3 – 60 kg topical x2

1) Apply twice daily to dry skin lesions 2) Continue for at least 10 days. 3) Can be used for all ages. 4) Do not apply to ulcerated skin lesions or mucus membranes. 5) Supplied as the nitrate.

ANTI-MALARIALS

Artemether + Lumefantrine (Coartem) Oral Malaria treatment

Administer Initially 8h 24h 48hr Total tablets

3 – 5 Kg 1/2 tab 1/2 tab 1/2 tab x 2 1/2 tab x 2 3

5 – 10 kg 1 tab 1 tab 1 tab X2 1 tab X2 6

10 – 20 kg 2 tab 2 tab 2 tab X2 2 tab X2 12

20 – 35 kg 3 tab 3 tab 3 tab x2 3 tab x2 18

> 35 kg 4 tab 4 tab 4 tab x2 4 tab x2 24

1) Dispersible tablets 20mg/120 mg per tablet 2) 6-dose regimen = initial dose followed at 8, 24, 36, 48 and 60 hrs by further doses 3) Avoid giving with Ciprofloxacin, Fluconazole, erythromycin 4) Tablets can be crushed 5) If dose is vomited within 1 hour repeat the dose 6) If Coartem not available, use Artemether-amodiaquine tablets at the same dose (not recommended because of

hepatotoxicity)

Artemether (IM - initial treatment for severe malaria)

Administer IM IM IM IM

day 1 only - loading dose subsequent days (max 7)

Presentation dose 20mg/ml 40mg/ml dose 20mg/ml 40mg/ml

1 time/day Ampoule ampoule ampoule ampoule

3 – 5 Kg 10-15mg 0.7 ml X 1 0.4ml x 1 5-8mg 0.4ml x 1 0.2ml x 1

5 – 10 kg 15-30mg 1.2 ml x 1 0.6 ml x 1 8-15mg 0.6ml x 1 0.3ml x 1

10 – 20 kg 30-65mg 2.5ml x 1 1.2 ml x 1 15-30mg 1.2 ml x 1 0.6 ml x 1

20 – 35 kg 85-110mg 4.5ml x 1 2.2 ml x 1 30-65mg 2.2 ml x 1 1.1 ml x 1

> 35 kg 110-170mg 7.0ml x 1 3.5ml x 1 85-110mg 3.5 ml x 1 1.8ml x 1

1) Dose 3.2mg/kg initially then 1.6 mg/kg x1, until patient can take oral medication 2) USE 1ml syringe to measure and give small doses 3) NOTE there are 20, 40 and 80mg/ml preparations available, do not use the 80mg/ml for small children 4) Maximum length of treatment 7 days 5) Always follow Artemether with complete (6-dose) oral course of Coartem 6) may affect plasma potassium levels and cardiac function 7) AVOID use with ciprofloxacin, Fluconazole and Erythromycin 8) The solution is made up in peanut oil

Artesunate (initial treatment severe malaria)

Administer rectal rectal IM or IV IM or IV

Presentation 50mg 200mg 60mg ampoule 60mg ampoule

Suppository Suppository

day 1 0 and 12hr

Daily

3 – 5 Kg 1 sup 1/4 sup 10mg x 2 10mg x 1

5 – 10 kg 1 sup 1/4 sup 20mg x 2 20mg x 2

10 – 20 kg 2 sup 1/2 sup 40mg x 2 40mg x 1

20 – 35 kg 4 sup 1 sup 60mg x 2 60mg x 1

> 35 kg 6 sup 2 sup 100mg x 2 100mg x 1

1) Rectal dose can be used initially 2) Rectal dose approx 10mg/Kg for ill children 3) NOTE IV/IM preparation prepared in 5% Sodium bicarbonate solution 4) For IV use further dilution in 5% glucose before IV infusion 5) Use with caution in kwashiorkor and heart failure because of sodium content 6) IV give 2.4mg/kg at 0, 12, 24hr and then daily until oral treatment can be given 7) Always follow with a full 6-dose course of Coartem

SCABICIDE

Permethrin (scabies/lice – ectoparasites)

Presentation Cream Lotion

5% 1%

3 – 60 kg once once

1) Apply over whole body, wash off after 12 hours. 2) If washed with soap within 8 hours repeat. 3) Ensure webs between fingers and toes, wrists, axilla, perineum and buttocks are covered. 4) Do not apply to mucus membranes, or ulcerated skin 5) Same chemical as used in Impregnated bed nets

HEART FAILURE

Furosemide / Frusemide (only for use in heart failure)

Administer Dose Oral Oral IV/IM

Presentation 0.5-2 mg/kg/dose suspension Tablet 10 mg/ml

2-3 times/ day 4 mg/ml 40 mg 2 ml ampoule

3 – 5 Kg 2 ml ¼ 1 ml

5 – 10 kg 5 ml ½ 2 ml

10 – 20 kg 10 ml 1 4 ml

20 – 35 kg 15 ml 1 5 ml

> 35 kg 20 ml 2 7.5 ml

1) Only use for HEART FAILIURE 2) NEVER give for oedema mobilisation (it can exacerbate oedema which is related to potassium deficiency) 3) For children normal oral dose 0.5-1mg/kg 4) Maximum oral dose 3 x 4mg/kg = 12mg/kg (80mg) per day 5) Normal IV dose 0.5-1mg/kg 6) Maximum IV dose 3 x 4 mg/kg 7) Causes loss of potassium, magnesium etc as well as sodium and water 8) Not ever effective in Heart failure in SAM – can use higher doses.

ALTERNATE MEDICINES that may be used when recommended medicines are unavailable

Ceftriaxone Administer IM/ IV

Dose 50-100mg/kg/d

Presentation 250mg/ vial

2 times/ day

3 – 5 Kg 100mg x 2

5 – 10 kg 200mg x 2

10 – 20 kg 400mg x2

20 – 35 kg 800mg x 2

> 35 kg 1g x 2

1) Prefer cefotaxime if available 2) CAREFUL: incompatible with Ringer Lactate and any calcium containing fluid - cefotaxime precipitates 3) Very painful if given IM 4) Can cause electrolyte disturbance, 5) Supplied as sodium salt 6) Gives false positive urinary glucose (reducing substances) and Coomb's test 7) For children maximum dose 1g

Amoxicillin + Clavulanic acid (Augmentin)

Administration Dose Oral Oral Oral

Preparation 25 - 50 mg/kg/d 125mg/5ml 250mg/5ml 500 mg

3 x per day suspension suspension tablet

3 – 5 Kg 62.5 mg x3 2.5 ml X 3

5 – 10 kg 125 mg x3 5 ml X 3 2.5 ml x 3 1/4 x3

10 – 20 kg 250 mg x3 10 ml X 3 5 ml X 3 1/2 X3

20 – 35 kg 500 mg x3 1 x 3

> 35 kg 750 mg x3 1 x 3

1) Exact dose not critical: can be doubled in case of severe infection with sensitive organisms 2) Ratio is fixed at 1mg of amoxicillin with 0.25mg clavulinic acid - dose expressed in terms of amoxicillin content 3) The risk of acute liver toxicity has been estimated to be about six times higher with amoxicillin+clavulanic acid than

with amoxicillin alone 4) The preparation contains sodium 5) The pharmacology of clavulinic acid has not been ascertained in SAM

Chloramphenicol Administration Dose Oral Oral IV

Presentation 25mg/kg/d 30mg/ml 250mg 1000mg

2 times/ day suspension capsule Vial

3 – 5 Kg Never give to small babies

5 – 10 kg 2ml x 2 1/4 x 2 75mg x 2

10 – 20 kg 4ml x 2 1/2 x 2 125mg x 2

20 – 35 kg 8ml x 2 1 x 2 250mg x 2

> 35 kg 12ml x 2 2 x 2 500mg x 2

1) Only use if there is no alternative or where microbiological facilities exist to show sensitivity and specific infections are diagnosed (e.g. typhoid fever, rickettsia, listeria, Wipple's disease, Q-fever, psittacosis)

2) Use cefotaxime, ceftriaxone or ciprofloxacin instead if available 3) Increases serum iron levels, therefore extra care needed in kwashiorkor. Iron increase is due to marrow toxicity 4) Never give to patients <5kg. In infants and those with immature liver function causes “grey baby syndrome”

(Vomiting, greenish diarrhoea, abdominal distension, hypothermia, pallid cyanosis, irregular respiration, circulatory collapse) which is clinically similar to severe sepsis/hepatic failure in SAM children

5) Do not use Oily suspension for injection (0.5g/ml)

ANNEX 7 – RUTF SPECIFICATION

Ready to Use Therapeutic Food (RUTF)

Severely malnourished patients have specific nutrient requirements that are different from normal children. These are best supplied using specialised therapeutic foods, such as F75, F100 and RUTF. Ready to use therapeutic food (RUTF) is an essential component of OTP as it allows patients to be treated at home. RUTF is a complete food for the severely malnourished, with a specific nutrient composition equivalent to F100.

There are currently several commercial types of RUTF: Lipid based pastes and bars. Several countries are producing their own RUTF using the standard recipe so that these products are nutritionally equivalent to F100, and have been shown to be physiologically similar to both F100 and the commercial RUTFs. An important difference between F100 and RUTF is that RUTF contains iron (in the correct amount for the recovering severely malnourished patient) whereas F100 used in the recovery phase requires iron supplementation.

RUTF-paste is a ready-to-eat therapeutic spread usually presented in individual sachets or pots. It is composed of vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar, and a mineral and vitamin complex.

Instructions for use: Clean drinking water must be made available to children during consumption of ready-to-eat therapeutic food. The product should only be given to children who can express their thirst. It is contra-indicated for children who are allergic to cow’s milk, proteins or peanuts and those with asthma or other allergic disease.

Recommendations for use: In the management of severe acute malnutrition in therapeutic feeding, it is recommended to use the product in phase 2 (two) in the dietetic management of severe acute malnutrition. In IPFs for phase 1 use milk based diet F75.

Storage of RUTF: Some commercial RUTFs (such as Plumpy’nut®) have a shelf life of 24 months from manufacturing date. Locally produced RUTFs that are not packed under nitrogen in a sealed container have a shelf life of 3 to 6 months. Keep stored in a cool and dry place.

Table: Mean Nutritional Value of RUTFs (based upon plumpy’nut®)

For 100 g Per sachet of 92 g For 100 g Per sachet of 92 g

Energy 545 kcal 500 kcal Vitamin A 910 mcg 840 mcg

Protein 13.6 g 12.5 g Vitamin D 16 mcg 15 mcg

Lipid 35.7 g 32.86 g Vitamin E 20 mg 18.4 mg

Calcium 300 mg 276 mg Vitamin C 53 mg 49 mg

Phosphorus 300 mg 276 mg Vitamin B1 0.6 mg 0.55 mg

Potassium 1 111 mg 1 022 mg Vitamin B2 1.8 mg 1.66 mg

Magnesium 92 mg 84.6 mg Vitamin B6 0.6 mg 0.55 mg

Zinc 14 mg 12.9 mg Vitamin B12 1.8 mcg 1.7 mcg

Copper 1.8 mg 1.6 mg Vitamin K 21 mcg 19.3 mcg

Iron 11.5 mg 10.6 mg Biotin 65 mcg 60 mcg

Iodine 100 mcg 92 mcg Folic acid 210 mcg 193 mcg

Selenium 30 mcg 27.6 mcg Pantothenic acid 3.1 mg 2.85 mg

Sodium < 290 mg < 267 mg Niacin 5.3 mg 4.88 mg

RUTF- bars (based upon BP-100®)

RUTF-bars are a compressed food product for use in the rehabilitation phase (Phase 2) of severely malnourished children and adults. The nutritional specifications are similar to therapeutic milk F100. As with the paste the RUTF-bars also contain iron.

Who to give RUTF-bars: Children from 12 months old, adolescents and adults who are severely malnourished in the rehabilitation phase (Phase 2) of the treatment. RUTF-bars should never be used for patients below 6 months old.

How to use RUTF-bars: they can be eaten as a biscuit directly from the pack together with sufficient drinking water (250ml to 300ml per bar), or crumbled into water and eaten as porridge. For children 12 to 24 months of age, the bars should always be given as porridge due to their problems demanding water when thirsty.

Storage of RUTF-bars: BP100® has a shelf life of 2 years in an unopened package. After breaking the aluminium foil bag the product should be used within 1-2 weeks depending on the storage conditions. Porridge made of BP100 and water should be used within 3 hours.

Packaging: BP100 is compressed into tablets of 28.4g. Each package of BP100 (510g net) contains 18 tablets packed into 9 bars in grease-proof paper (1 bar = 2 tablets = 300 Kcal).

Local production of RUTF

The minimum required ingredients for RUTF are as follows:

Four basic ingredients of RUTF: sugar; Dried Skim Milk; oil; and a vitamin and mineral supplement. In addition up to 25% of the weight of the product can come from vegetable sources such as oil-seeds, groundnuts or cereals such as oats provided that the nutrient density is the same as that found in F100.

In addition to good nutritional quality (protein, energy and micronutrients), RUTF should have the following attributes:

taste and texture suitable for young children

does not need additional processing such as cooking before consumption

resistant to contamination by micro-organisms and a long shelf life without sophisticated packaging

ingredients are low cost and readily available in developing countries

Recently WHO/UNICEF/WFP/SCN have produced DRAFT specifications for RUTF. They are as follows:

Ready to use therapeutic food.

High energy, fortified ready to eat food suitable for the treatment of severely malnourished children. This food should be soft or crushable, palatable and should be easy for young children to eat without any preparation. At least half of the protein contained in the product should come from milk products.

Nutritional composition:

Moisture content

Energy

Proteins

Lipids

Sodium

Potassium

Calcium

Phosphorus (excluding phytate)

Magnesium

Iron

Zinc

Copper

Selenium

Iodine

Vitamin A

Vitamin D

2.5% maximum

520-550 Kcal/100g

10 to 12 % total energy

45 to 60 % total energy

290 mg/100g maximum

1100 to 1400 mg/100g

300 to 600 mg/100g

300 to 600 mg/100g

80 to 140 mg/100g

10 to 14 mg/100g

11 to 14 mg/100g

1.4 to 1.8 mg/100g

20 to 40 µg

70 to 140 µg/100g

0.8 to 1.1 mg/100g

15 to 20 µg/100g

Vitamin E

Vitamin K

Vitamin B1

Vitamin B2

Vitamin C

Vitamin B6

Vitamin B12

Folic acid

Niacin

Pantothenic acid

Biotin

n-6 fatty acids

n-3 fatty acids

20 mg/100g minimum

15 to 30 µg/100g

0.5 mg/100g minimum

1.6 mg/100g minimum

50 mg/100g minimum

0.6 mg/100g minimum

1.6 µg/100g minimum

200 µg/100g minimum

5 mg/100g minimum

3 mg/100g minimum

60 µg/100g minimum

3% to 10% of total energy

0.3 to 2.5% of total energy

Reference document for F100 composition: Management of severe malnutrition - a manual for physicians and other senior health workers. WHO, Geneva, 1999. Available at: http://www.who.int/nutrition/publications/en/manage_severe_malnutrition_eng.pdf

Note: iron is added to RUTF in contrast to F100.

Safety: The food shall be free from objectionable matter; it shall not contain any substance originating from micro-organism or any other poisonous or deleterious substances like antinutritional factors, heavy metals or pesticides in amounts that may represent a hazard to health of severely malnourished patients.

Aflatoxin level: 5 ppb maximum.

Micro-organism content: 10 000/g maximum

Coliform test: negative in 1 g

Clostridium perfringens: negative in 1 g

Yeast: maximum 10 in 1 g.

Moulds: maximum 50 in 1g.

Pathogenic Staphylococci: negative in 1 g.

Salmonella: negative in 125g

Listeria: negative in 25g

The product should comply with the International Code of Hygienic Practice for Foods for Infants and Children of the Codex Alimentarius Standard CAC/RCP 21-1979. All added mineral and vitamins should be on the Advisory List of Mineral Salts and Vitamin compounds for Use in Foods for Infants and Children of the Codex Alimentarius Standard CAC/GL 10-1979

The added mineral salts should be water soluble2 and readily absorbed, they should not form insoluble components when mixed together. This mineral mix should have a positive non-metabolizable base sufficient to eliminate the risk of metabolic acidosis or alkalosis. 3

Information on how to produce RUTF in countries is available at: http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/CBSM/tbp_4.pdf

2 Many manufacturers use insoluble salts such as magnesium hydroxide, zinc oxide, ferrous fumarate, copper oxide etc. This is unacceptable as although these salts are cheap and tasteless, they are not available for the malnourished child. Any RUTF made with these salts should be rejected by the purchaser as failing to conform with the generic specifications. 3 The nonmetabolizable base can be approximated by the formula: estimated absorbed mmoles (sodium + potassium + calcium +

magnesium) - (phosphorus+chloride). The mineral mix recommended for F100 by WHO is an example of mineral mix with suitable

positive nonmetabolizable base.

DATE

ANNEX 8: DAILY WARD FEED CHART

WARD:

Name of Child

F-75 F-100

Number feeds

Amount/ feed (ml)

Total (ml)

Number feeds Amount/ feed

(ml)

Total (ml)

F-75 (total ml) needed for 24 hours F-100 (total ml) needed for 24 hrs

Amount needed for hours* Amount needed for hours*

Amount to prepare (round up to whole litre) Amount to prepare (round up to whole litre)

*Divide daily amount by the number of times food is prepared each day. For example, if feeds are prepared every 12 hours, divide daily amount by 2.

Annexes

ANNEX 9: AMOUNTS OF F-75 TO GIVE

Give the amounts in the table below to each patient.

Table 8: Amounts of F75 to give during Acute-phase (or Stabilization Phase)

CLASS OF WEIGHT (KG) 8 FEEDS PER DAY ML FOR EACH FEED

6 FEEDS PER DAY ML FOR EACH FEED

5 FEEDS PER DAY ML FOR EACH FEED

2.0 to 2.1 kg 40 ml per feed 50 ml per feed 65 ml per feed

2.2 – 2.4 45 60 70

2.5 – 2.7 50 65 75

2.8 – 2.9 55 70 80

3.0 – 3.4 60 75 85

3.5 – 3.9 65 80 95

4.0 – 4.4 70 85 110

4.5 – 4.9 80 95 120

5.0 – 5.4 90 110 130

5.5 – 5.9 100 120 150

6.0 – 6.9 110 140 175

7.0 – 7.9 125 160 200

8.0 – 8.9 140 180 225

9.0 – 9.9 155 190 250

10 – 10.9 170 200 275

11 – 11.9 190 230 275

12 – 12.9 205 250 300

13 – 13.9 230 275 350

14 – 14.9 250 290 375

15 – 19.9 260 300 400

20 – 24.9 290 320 450

25 – 29.9 300 350 450

30 – 39.9 320 370 500

40 – 60 350 400 500

Annexes

ANNEX 10: MULTI-CHART

Annexes

Annexes

Annexes

The other routine treatments are the same as that given to OTP patients: 1) de-worming, 2) measles vaccination and 3) vitamin A before being discharge.

The Criteria to move back from Phase 2 to the Acute Phase (Phase 1) in the IPF are the same as given for OTP patients.

The discharge criteria are the same as those given for OTP patients.

Annexes

ANNEX 11 – HOW TO INSERT AN NGT

Choose the appropriate size tube (range is 6, 8 or 10 FG). Lie infants on their back, swaddled in a small blanket as a mild restraint.

Measure the tube from the child’s ear to the tip of the nose and then to just below the tip of the sternum (for pre-term and neonates from the bridge of the nose to just beyond the tip of the sternum). Hold or mark this position so that you know how far to insert the tube.

Lubricate the catheter with a jelly type lubricant, vaseline or at least water and insert through the nose bending the tube slightly upwards to follow the nasal passage.

Bend the head slightly backwards to extend the neck. Insert the catheter smoothly and quickly at first pushing upwards (not just backwards) so that the catheter bends in one loop downwards along the back of the throat. Do not push against resistance (if you cannot pass the tube through the nose, pass it through the mouth instead). Take care that the tube does not enter the airway. If the child coughs, fights or becomes cyanotic, remove the tube immediately and allow the patient to rest before trying again. It is vital to check that the tube is in the stomach before anything is put down the tube. This should be re-checked before each feed is given in case the tube has been dislodged from the stomach. Note that sick, apathetic children and those with decreased consciousness can have the tube passed directly into their lungs without coughing. It is not a guarantee that the tube is in the right place just because it has passed smoothly without complaint from the child.

The best way to test that the tube is fully in the stomach is to aspirate some of the stomach contents and test for acid with litmus paper. The stomach contents in normal children are acid and turn blue litmus paper red. However, the malnourished frequently have “achlorhydria” (lack of gastric acid). In the absence of litmus paper and in the malnourished child check that there is the characteristic appearance and smell of stomach contents (“sour” or like vomit).

Also check the position by injecting 0.5 – 1ml of air into the tube whilst listening to over the stomach with a stethoscope. A “gurgling” or bubbling sound can be heard as air enters the stomach.

It is always best to ask someone else to check if you are not sure the tube is in the right place, to avoid the risk of milk going onto the lungs. Before each feed, aspirate the tube to check that the previous feed has left the stomach; this may be slow and gentle in very sick children as strong suction can damage the stomach lining. It is important not to cause gastric distension by giving a new feed on top of an old one4. The flow of the feed should be slow.

Attach the reservoir (10 or 20 ml syringe) and elevate it 15 – 20 cm above the patient’s head. The diet should always be allowed to flow into the stomach by gravity and not pushed in with the plunger. When the feed is complete, irrigate the NGT with a few ml of plain water and stopper the tube (or clamp it). Place the child on his/her side to minimise regurgitation and aspiration. Observe the child after feeding for vomiting, regurgitation or abdominal distension.

In an IPF the tube should be changed every 3-5 days.

4 If there is « sour » gastric juice, with flocculant old food suspended in it, then this should be completely aspirated, the volume noted and about 20ml of isotonic sugar solution passed down the tube and immediately reaspirated to « irrigate » the stomach. The stomach is then allowed to rest for about 30 minutes before the diet is re-introduced. If after 3 hours this second feed has not passed out of the stomach then the volume of the diet will need to be reduced and/or the frequency increased.

Annexes

ANNEX 12: SIMPLE TOYS FOR EMOTIONAL AND PSYCHOLOGICAL STIMULATION

© Professor S. Grantham-McGregor

Annexes

ANNEX 13: RUTF RATION CHART

RUTF can be used for in-patients. The advantages of use in the IPF are that it requires less staff time and supervision, no preparation is necessary, the food can be taken throughout the day and the mother can feed the child by herself overnight; there is also no need to give the child additional iron.

Some children prefer F100 and others RUTF. However, taking a single food for several weeks is monotonous and many older patients welcome a change in diet. One can give F100 during the day when there are adequate staff and RUTF for evening and overnight feeding.

Give the amounts shown in the table.

The amount of F100 or RUTF to OFFER at each feed for 5 or 6 feeds per day or RUTF for the whole day to be used in the recovery phase in an IPF: If the patients take the whole amount then more should be offered

Class of weight Kg

6 feeds/ day 5 feeds/day Whole† day

F100 RUTF F100 RUTF RUTF

ml/feed g/feed ml/feed g/feed g/day

<3 kg Full strength F100 and RUTF are not given below 3kg: use F100dilute

3.0 to 3.4 110 20 130 25 120

3.5 – 3.9 125 20 150 25 130

4.0 – 4.9 135 25 160 30 150

5.0 – 5.9 160 30 190 35 175

6.0 – 6.9 180 35 215 40 200

7.0 – 7.9 200 35 240 45 220

8.0 – 8.9 215 40 260 45 235

9.0 – 9.9 225 40 270 50 250

10.0 – 11.9 230 45 280 50 260

12.0 – 14.9 260 50 310 60 290

15.0 – 19.9 300 55 360 65 330

20.0 - 24.9 370 65 440 80 400

25.0 – 29.9 420 75 500 90 450

30.0 – 39.9 450 80 540 100 500

40 – 60 530 100 640 120 600 †One sachet of commercial RUTF contains about 92g and 500kcal (one gram = 5.4kcal)

When RUTF is given, as much water as satisfies the patient’s thirst must be offered during and after each feed. Because RUTF can be kept safely the amount for the whole day can be given once per day. This is then eaten at the patient’s leisure, in his/her own time. But the aid-nurse should periodically check on the amount taken, assess the child’s appetite and ensure that the caretaker does not consume the diet.

Note: Iron is added to the F100 in Phase 2. Add 1 crushed tablet of ferrous sulphate (200mg) to each 2 litres to 2.4litres of F100. For lesser volumes: 1000 to 1200ml of F100, dilute one tab of ferrous sulphate (200mg) in 4ml water and add 2ml of the solution. For 500ml to 600ml of F100, add 1ml of the solution. Alternatively, if there are few children, iron syrup can be given to the children.

RUTF already contains the necessary iron.

Annexes

Annexes

ANNEX14: INFANT SS

CHART

SAM-Number……………………………..

Registration No……………………………………IPF Code………………………. Admission Date___/___/__ Discharge Date___/___/___

Sheet No……………………………………………IPF Name………………… Time………………...am/pm Successfully Treated

Family Name Day care/Pediatric W/Other 1 …………………………… New Admission □ Dead Time ….………...am/pm …………..

Patient's Name…………………………………………Age (day or mo.)…………………2 …………………………… Relapse Cause of death.............................................

Address………………………………………………………….Birthdate___/___/___ 3 …………………………… Readmission Y / N Defaulter

………………………………………………………….Sex…………………… Breastfed……………....Y / N If Y, Type Med. Referral To……………… …………..

Phone-No……………………… Receiving other feed…..Y / N Reg No …………………… Non Response to treatment

Reason admission 1) Grow th Monitoring static: Y / N - 2) Weight/Length...Y / N 3) Weight/Age Y / N 4) Complication Y / N if Y ....................... - 5) Œdema Y /N

Date

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Length (cm)

Weight (kg.g)

Wt for Ht (Z/%)

Œdema (0 to +++)

Date

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

# feeds/day

Infant Formula/F100Dil

SS ml / feed

A=AbsentV=Vomit 2

R=RefusedNG=tube 3

IV=IV Fluid4

Amounttaken 5

6

7

8

9

=ml=extra 10

Alert/Lethargic (A/L)

Stool ( 0 to IIII)

Vomit (0 to IIII)

Dehydrated (0 to +++)

Cough (0 to +++)

Shock (0 to +++)

Resp. rate /mn

Pale Conjunct. (0 to +++)

Temp. AM (Ax/Rec)

Temp. PM (Ax/Rec)

SS-Chart for Infants with SS feeding (less than 6 months or 3kg)

Major Problems

100%

An

thro

po

me

try

1/2

Th

era

pe

uti

c D

iet

Su

rve

illa

nc

e

We

igh

t C

ha

rt

1/4

Time Hr1

3/4

X XX X

X

XX

X XX

Annexes

Annexes

ANNEX15: IPF MALNUTRITION RECORD BOOK MALNUTRITION RECORD BOOK IN STABILIZATION CENTRE

Int. Transfer

S/N Reg No SAM No Patient Name Family Name Address & Phone NoType of Admission Code/Name of SC/OTP

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Int. transfer out

SC/OTP

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

S/N Date Wt kg/g W/L or H

Oedema 0,1,2,3 MUAC cm

Oedema

0,1,2,3MUAC cm

Exit from SC Type of Exit

Date of

minimum

weight

Minimum

weightObservationType

Entry to Stabilization Centre

Sex M/F Age in Mo Wt kg/g Ht/L cm W/L or H

Annexes

ANNEX 16: INFANTS WITHOUT THE PROSPECT OF BEING BREASTFED

F100 DILUTE LOOK UP TABLE

Look up table of the amounts of Generic Infant formula, F100dilute or F75 to give for infants not breast-fed in the Acute, Transition and Recovery phases.

Acute Phase Transition Phase Recovery Phase

Class of weight (kg) Amount (ml) of Generic Infant Formula F100dilute or F75 to give per feed

8 feeds/day 8 feeds/day 6 feeds/day

≤ 1.5 kg 30 40 60

1.6 – 1.8 35 45 70

1.9 – 2.1 40 55 80

2.2 – 2.4 45 60 90

2.5 – 2.7 50 65 100

2.8 – 2.9 55 75 110

3.0 – 3.4 60 80 120

3.5 – 3.9 65 85 130

4.0 – 4.4 70 95 140

CRITERIA for DISCHARGE

When the infant reaches -1.5Z score weight-for-height and is gaining weight at 20g/d s/he can be discharged.

The infants will be discharged on generic infant formula.

It is essential that the caretaker has access to adequate amounts of generic infant formula. This has to be supplied by the clinic or orphanage/foster parents. Commercially produced formulae are nearly always unaffordable by families with malnourished young infants when no mother or wet-nurse is available. Most caretakers5 (fathers, siblings) in this situation over-dilute the formula to make it “stretch” and last longer, others use the cheapest milk, which will be dried whole milk, evaporated or condensed milk; these are all unsuitable for the growth and development of the previously malnourished infant.

The caretaker (father/siblings) must have the knowledge and facilities to prepare the formula milk safely.

Follow-up for these infants and their caretakers is very important and should be organised by the outreach worker in conjunction with the community volunteers.

5 In many areas with a high prevalence of HIV there are substantial numbers of “child-headed households”, where the adults have all died. These children looking after children present a particular difficulty in terms of livelihood, knowledge, exploitation etc. The whole household needs direct assistance.

Annexes

ANNEX 17: TRANSFER FORM

Annexes

ANNEX 18: IPF MONTHLY REPORTING FORM

Name of Facility Report prepared by

Facility Code Report period from DD MM YYYY

Type of Facility Report period to DD MM YYYY

State Date of Submission

LGA List of OTPs outside LGA using this SC

Month of Reporting

Age Group

Total beginning of the

month (Beg)

READMISSION

after

defaulting

(<2months)

INTERNAL

TRANSFER

(from OTP

or

another

SC)

Total

Entry to

SC

Transfer

<6monthsW/H<-3 Z-score or

MUAC <11.5cm Oedema Relapse

SUCCESSFULLY

TREATED/

Internal transfer

DEAD (Dead)DEFAULTER

(Defn)

NON-

RESPOND

ER/MEDIC

CURED

(Dcur)

6-11months

12-59months

>59months

Total

% % % %

Errors of

Admission NoProducts In Out Balance

F75 (sachet)

F100 ( Sachet)

RUTF (Box)

Medicines In stock In Out Balance

INPATIENT FACILITY MONTHLY REPORT ON MANAGEMENT OF SAM

Defaulter = Patient that is absent for 2 consecutive weighing (2 days)

Succesfully treated (Tout)= Patient has been successfully treated & transferred to an OTP Or is gaining weight on exclusive breastmilk

Non-response/Medical referral (Dmed) =Patient that has failed to respond to treatment and has been referred to another service/hospital who will take over management

Internal transfer (from OTP or another SC) {Tout}=patient that was in the SC and is transferred to an OTP to continue treatment

Total end of the month (End) = Total beginning of the month (Beg) + Total admissions (Cin) -Total exit (Tout)

Total Exit

(Cout)

* for 500ml 0r 21New admissions= Patients directly admitted to SC ( Acute-phase 1) without SAM Number assigned.

Internal transfer (from OTP or another SC) {Tin}=patient that was in an OTP or another SC & has been transferred to the SC

Dead (Dead) = Patient that has died in the SC

New Admissions OTHER EXITS FROM THE SC

Total end

of the

month

(End)

Annexes

ANNEX 19: IPF SUPERVISION FORM

Date: _____/_____/______ State:______________ LGA _________ Facility

name/code:______________

Month of the last visit…………………By...........………………

Supervision visit during FEEDING? Yes / No

Person interviewed the day of the visit

Name Position Qualification Employed by

STAFF & TRAINING

Staff of the IPF/SC

Grade/

Qualificatio

n

Number Responsibl

e for

Salaries/

Incentives

given

last month

Training on

SAM if Yes, date

of the last training

Length of

time in SC: no expected to

transfer/leave

soon

Present/Absent on

day of the visit – if

absent give reason

(ill/leave etc)

Conclusion & Actions taken:__________________________________________________________

__________________________________________________________________________________

IP Guidelines

Copy of the protocol? Yes / no If Yes, Version No:_____________

Posters on the wall? Yes / No. If Yes, which ones?_________________________________

Protocol READ? Yes / no KNOWN? Yes / No DIFFICULTIES UNDERSTANDING? Yes / No

If Yes, which parts? _________________________________________________________________

Conclusion & Actions taken:__________________________________________________________

_________________________________________________________________________________

STRUCTURE

Integrated within the SPHCDA/MoH? Yes / no

Health Centre: Yes / no - Hospital: Yes / no - Other Yes / no

Specify…………………………………………………………………...……………………………………………………………………………

Annexes

Type of structure: Separate IPF / IPF in Paediatric Ward/ Day Care Non-Residential/ Residential /

Other ………………………………………………………………………

Organisation responsible:............................... SPHCDA/MoH / Private / NGO

/Other specify……………………..

Reference Centre for ALL the OTPs in all the Local Government Areas.

…..................................................................................……………………………..

OPD Yes / no Screening ? Yes / No If Not, why? _____________________________

Register?___________Lenght board?_______scale?_______MUAC?_______________

If Not, why?____________________________________________________________________

Emergency Ward: Screening? Yes / No If Not, why? ___________________________________

Register?___________Lenght board?_______scale?_______MUAC?_______________

If No, why?____________________________________________________________________

Posters? Yes / no Guidelines/ Protocol? Yes / No Emergency Staff trained? Yes / No

Storage:

Therapeutic products separate from the IPF Yes / no If yes, specify_________________

Drugs Yes / no If yes, specify__________________________________________________

Other Material Yes / no If yes, specify________________________________________________

Conclusion & Actions taken:__________________________________________________________

_________________________________________________________________________________

TOOLS – MATERIALS – PRODUCTS

Anthropometric material present and in good condition? Yes / no

If not, MUAC_____Length board_________Scale_____________Others_________

IMAM Register used? Yes / no

Multi-Charts used? Yes / no SS-Infant Charts Yes / no Critical care charts Yes / no

Other records kept (hospital charts) Yes / no

Transfer form? Yes / no

Look up Tables? Yes / no If no, which ones are missing?______________________________

Drinkable water available? Yes / no If No, Actions taken______________________________

Hand-washing facilities within IPF Yes / no. If yes are they used? Yes / no

Sugar water available? Yes / no If No, Actions taken_________________________________

F75 present and used Yes / no – commercial / made in IPF

F100 present and used Yes / no – commercial / made in IPF

Annexes

RUTF available and used? Yes / no

ReSoMal available and used Yes / no

Routine medicine available? Yes / no If not, which ones?_____________________________

Specific drugs available? Yes / no; If no, which ones? _______________________________

Blood transfusion available Yes / no

Laboratory/radiology facilities available Yes / no – if yes, which tests...................................

Health Education materials available? Yes / no

Toys for children present? Yes / no On beds / on floor / locked away

Conclusion & Actions taken: __________________________________________________________

__________________________________________________________________________________

ACTVITIES OBSERVED (on patients and/or written on the charts)

Observed or Written on the

charts of the 2 last months Checked

Totally

Adequate

Directly

observed

Quality

Remarks A

+1

B

+.5

C

-.5

D

-1

1-Screening

Screening in OPD

Screening in Emergency W.

No Transferred appropriately

No Transfer Form filled in

No Patients referred directly

2-Measurements

Length/height checked

Weight

MUAC

Oedema & degree

WH Z score

3-Admission

Sugar water /drinking water

available

Medical History

&examination form filled in

Appetite Test

Transfer form with SAM-No

Register & SAM No

4-Management Acute Phase

Breastfeeding before feeds

Washing hands before feeds

F75 Feeds prepared

Feeds given, observed &

chart completed

Syst. Treatment

Annexes

Multichart filled

Critical care charts used

properly

Other specific drugs given

Criteria for Transition phase

respected

Fail-to- Respond in SC

recognised and managed

5-Transition Phase & exit

RUTF/F100 given & written

Feeds well given

Water available

Health Education given

Type of exit written on the

chart and register completed

6-Less than 6 months

Treatment implemented

SST- Chart used & filled-in

F100 dilute preparation

Treatment correctly applied?

Position of the mother &

infant during SS-T?

Systematic treatment given?

7-Stock

Stock card of Therapeutic

foods maintained and

updated

Stock card of routine drugs

updated

8-Monitoring

Internal Transfer noted in the

register? Form attached to the

IPF chart?

Transfer Criteria applied.

Monthly report from last

month filled in correctly

Monthly report sent on time

Charts kept securely in order

by SAM No and registration

No

9-Coordination

Attend regular meetings with

IMAM team

Good communication with

OTPs

Annexes

Transport arranged with the

LGA for patients and

products?

Total

CONCLUSION & ACTION TO BE TAKEN FOR THE NEXT MONTH

Date ______________ Signature of person interviewed ____________________

Signature of Evaluator____________________________